THE PLANTAR REFLEX - RePub

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eflex arc must have its impact at or near these motoneurones. In other words, an excitatory action (direct and selective innervation of distal motoneurones) is closely connected with an inhibitory action (counteracting the recruitment of the extensor hallucis longus via the flexion reflex pathways). The inhibitory neurone might be activated by collaterals of corticomotoneuronal fibres or consist of separate, but intimately related, pyramidal fibres. The proposed interaction between descending tracts and flexion reflex pathways is represented schematically in figure 14. Nevertheless, there are exceptions. Some patients show a Babinski sign together with other pyramidal features but without demonstrable weakness or loss of skill (cases 1-4, table XVIII), others lack it whilst having some motor deficit in the foot (case 5, table XX). There are two ways of explaining these inconsistencies. The first is that direct excitation of distal motoneurones and inhibition of impulses via flexion reflex afferent nerve fibres can be dissociated because they are mediated by different neurones, however closely they are linked. The alternative is to invoke individual factors in exceptional patients: motor abnormalities that are too subtle for testing on the one hand, and an idiosyncratically poor influx of segmental impulses to motoneurones of the extensor hallucis longus on the other. Bilateral Babinski signs without other pyramidal features In normal subjects, even in those with rather brisk flexion reflexes, a normal pyramidal system keeps the extensor hallucis longus muscle out of the flexion reflex synergy, at least after infancy. This is of course the basis for the great practical value of the plantar reflex. However, one meets exceptional cases where extremely brisk flexion reflexes are found on both sides, in the absence of other abnormalities: mere touch activates all flexor muscles of the leg, including the extensor hallucis longus, and this can be reproduced indefinitely. Two such patients were described in Chapter IV. One had sustained a (probably) epileptic seizure two years before and the other showed a raised CSF protein, but in neither were there abnormalities on neurological examination. Rather than to invoke an occult disturbance of distal pyramidal projections, it may be more reasonable to assume that in these patients the flexion reflex - either released from supraspinal control or being only at one extreme of normal variation - breaks through the normal descending control of extensor hallucis longus motoneurones. That such a view is not too heretical is illustrated by the fact that up going toes can be produced in many normal subjects by stimulating the base or pads of the toes (Verger and Abadie, 1900; Dosuzkov, 1932). It is unnecessary to honour Babinski by postulating absolute impermeability of extensor 142
PYRAMIDAL TRACT PYRAMIDAL AND RETICULOSPINAL FIBRES A iliopsoas B t rostral I I I I I I I I I I I caudal I .. ' ' ' /'- extensor hollucis longus (L5) ~ >----'" tibialis anterior (l4-5) tensor fasciae Ia toe (L4-Sl) biceps femoris and semitendinosus (L5-Sl) distal +--------+proximal FIGURE 14 PROPOSED INTERACTION OF PYRAMIDAL TRACT AND FLEXION <strong>REFLEX</strong> PATHWAYS IN <strong>THE</strong> SPINAL CORD A -direct pyramidal control of dirtal motoneurones. Ll)ith local inhibition of flexion reflr::x pathwayJ; dysfunction causes loss of skill and releases the R1binJki sign. B -descending control of interneuronex which mediate the flexion reflex; dy.rfunction releaseJ the flexion reflex as a whole, but this iJ not essential for the appeMctnce of a Babinski sign. 143
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THE PLANTAR REFLEX a historical, cl
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THE PLANTAR REFLEX A HISTORICAL, CL
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Aan mijn ouders Aan Carien, Maarten
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TELEOLOGICAL SPECULATIONS - science
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- EMG result and 'final' neurologic
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LIST OF ILLUSTRATIONS figure page 1
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Electromyographic recording from mu
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The plantar reflex before Babinski
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viz. those of Striimpell (1899), Op
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These early reports did not reach m
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Charcot's concepts about hysteria w
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TABLE I STUDIES CONFIRMING BABINSKI
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False positive findings? Babinski's
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FLEXION AND EXTENSION SYNERGIES The
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confirmed by Walshe (1914). His is
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esult in disappearance of the Babin
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without an ipsilateral upgoing toe
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RIVAL SIGNS Confusion When Babinski
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8. Stroking the anterior surface of
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Contradictory findings THE PLANTAR
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Bersot 1920,'2! ? X ]l 2 Burr 1921
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curious case of one healthy infant
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9. Infants under one year of age ge
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INTRODUCTION Observer error: examin
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following a suggestion that most re
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TABLE IV INFORMATION PRECEDING THE
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TABLE VI RATINGS OF 'INFORMATION' G
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unm i stakab I y upward possibly up
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Clinical experience appeared to be
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CHAPTER III BABINSKI SIGN: STIMULUS
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TABLE VII CLINICAL COMMENTS ON THE
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Normal plantar response: flexor hal
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I. rn. extensor hallucis longus 2.
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TABLE VIII OCCURRENCE OF REFLEX ACT
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ecruited and even interrupted by EH
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value (the minimal stimulus intensi
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FIGURE 8 Relative dimen.riom and we
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the two separate bursts of electrom
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5. In general, reflex effects produ
Page 87 and 88:
INTRODUCTION When is an upgoing toe
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stimulated side diminishes extensor
Page 91 and 92: 30 patients with equivocal plantar
Page 93 and 94: A FHB EHL E TA EHL c FHB TA _j1mV 5
Page 95 and 96: Inexperienced observer An additiona
Page 97 and 98: patient 2 3 4 5 6 7 8 sex F M M F F
Page 99 and 100: Practical use of the flexion reflex
Page 101 and 102: 1. Contraction of the tibialis ante
Page 103 and 104: FHB I ! ¥ _j 02 FHB ...,. r~~a..,.
Page 105 and 106: Finally the method of stimulation.
Page 107: CHAPTER V THE BABINSKI SIGN AND THE
Page 110 and 111: TABLE XIV THEORIES INVOKING A SUPRA
Page 112 and 113: change of the plantar reflex was of
Page 114 and 115: An upgoing toe response in lower pr
Page 116 and 117: noticed no special features, and of
Page 118 and 119: 'pyramidal syndrome' were not. Thei
Page 120 and 121: movements, but also the capacity to
Page 122 and 123: - rapid foot tapping on the couch,
Page 124 and 125: TABLE XVI FREQUENCY OF V ARlO US SI
Page 126 and 127: ~ N 0\ TABLE XVIII PATIENTS WITH A
Page 128 and 129: ~ N 00 TABLE XIX LACK OF CORRELATIO
Page 130 and 131: ~ '->' 0 TABLE XX PATIENTS SHOWING
Page 132 and 133: 3. BABINSKI SIGNS APPEARING IN OR D
Page 134 and 135: --------------~~- ~ '-" TARLE XXI "
Page 136 and 137: DISCUSSION Two principal features e
Page 138 and 139: patients in the first group in whom
Page 140 and 141: The most striking examples of Babin
Page 144 and 145: hallucis longus motoneurones to seg
Page 146 and 147: 9. The paradoxical downward toe res
Page 148 and 149: showed very little agreement with t
Page 150 and 151: A second condition to be fulfilled
Page 152 and 153: eide met dubieuze voetzoolreflexen,
Page 154 and 155: waarin de Babinski-reflex verdween,
Page 156 and 157: BABINSKI,]. (1885). Recherches sur
Page 158 and 159: approche d'une interpretation du si
Page 160 and 161: BUCK, D. de, and MOOR, L. de (1900)
Page 162 and 163: DEJERINE, ]., and LEVY V j\LENSI, J
Page 164 and 165: FRIEDMAN, E. D. (1920). On a possib
Page 166 and 167: GROSS, F. (1971). The Emperor"s clo
Page 168 and 169: IIDA, M., and BASMAJIAN,]. V. (1974
Page 170 and 171: LANDAU, W. M., and CLARE, M. H. (19
Page 172 and 173: MANFREDI, M., SACCO, G., and SIDER!
Page 174 and 175: NYBERG-HANSEN, R., and RINVIK, E. (
Page 176 and 177: lombo-sacrCe avec amyotrophie globa
Page 178 and 179: STRDMPELL, A. VON (1887). Ueber ein
Page 180 and 181: WALSHE, F. M. R. (1956). The Babins
Page 183 and 184: ACKNOWLEDGEMENTS I am grateful for
Page 185: CURRICULUM VITAE De schrijver van d
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